COPD Undertreatment Actually Led to Fewer Exacerbations, Study Finds

A study of patients with chronic obstructive pulmonary disease (COPD) treated at a Veterans Administration (VA) hospital in New York found an unexpected relationship: the veterans who were undertreated according to treatment guidelines had lower rates of COPD exacerbation events.

Researchers followed a cohort of 878 patients with COPD from 2005 to 2010 at the Northport VA Medical Center and identified their COPD severity, prescribed treatments, and any events of exacerbation, which were defined as a hospitalization or outpatient visit for respiratory symptoms where the patient was prescribed steroids or an antibiotic. Their findings were published this month in the International Journal of Chronic Obstructive Pulmonary Disease.

During the study period, the VA used the guidelines issued by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2004. The researchers classified the subjects based on their actual treatment regimen indicated in their electronic medical record, and compared their treatment to the regimen suggested for their COPD severity stage according to the GOLD guidelines. These guidelines defined the stage of severity based on spirometric measurements of airway blockage, and added an additional therapy for each increase in severity stage.

Based on these guidelines, just 18.7% of patients were treated appropriately for their COPD stage. Undertreatment, or receiving the regimen recommended for a less severe stage, occurred in 44% of patients. The remaining patients were either overtreated or received a therapy not indicated in the guidelines.

As predicted by the researchers based on previous literature, the rate of exacerbations increased with increasing severity of obstruction, but these rates were “substantially lower than those reported in a meta-analysis of the literature for each GOLD category,” they wrote. The most notable finding was the strong negative correlation between undertreatment and exacerbation rate, meaning that patients who were undertreated according to the GOLD guidelines actually had fewer exacerbations.

These results, according to the authors, suggested that “clinicians were using exacerbation rate as an important determinant of therapy” as opposed to the spirometric criteria of the guidelines. In 2011, a year after the study period ended, GOLD revised its guidelines to include patients’ exacerbation rates in determining their treatment plans, just as the clinicians had already done.

"What happened was that the physicians here in the VA were adjusting their treatments depending on what happened with the patients,” explained lead study author Hussein Foda, MD, in a press release. “If the patients did not get exacerbations, their doctors reduced their medication, even though it was recommended in the guidelines to increase.”

Foda also pointed to a number of factors specific to the VA healthcare system that may have contributed to the lower exacerbation rates and more frequent undertreatment. The VA medical center examined in the study had a 90% vaccination coverage rate for flu and pneumonia, which could have prevented some COPD flare-ups. Patient adherence to treatment may have been better because the VA pays for eligible patients’ medications.

He also commended the VA’s more proactive screening practices of regularly testing long-term smokers’ lung function. In contrast, patients in the private sector often are not diagnosed until they visit their care provider with COPD symptoms.

These findings provide some important lessons for other illnesses and care settings. Comprehensive preventive services can potentially reduce healthcare utilization due to chronic conditions, while provider nonadherence to guidelines could indicate the need to reevaluate those recommendations.